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•n • . • DANE CUUNIT ruDU•-••-••-VI <br /> ENVIRONMENTAL 12ALTH DIVISION <br /> 1406 AjGthport Dr., Room 101 <br /> .. . _. . • ,. <br /> , . <br /> pitz. 6 7 ./. Madan. nsm 53704 <br /> k m, j rate and County . �0 State Permit# <br /> �\ j,'t f 'ermit Application J ^r County Permit# � <br /> )6, , r ! <br /> for Privat: Domestic wage Sy !rf!sl 3 198 County �/ - <br /> 'DENOTES STATE APPROVAL REQUIRED <br /> ban, <br /> O <br /> Date Approval Received from State if Required f•eq/f/2,N.6044/14.4..Env; # <br /> ' .: af.jL:/ <br /> A. OWNER OF PROPERTY Mailing Address: <br /> c��&}Eo,c 6,-a ecHOc_ , i9^" 0 c/./ s4- -. <br /> 7/o 669,v RERCh/MSECcE2 J'cFes/c aioGF ',C. 't/,0»L.P"r" .••••-•S La/f <br /> B. LOCATION: 4/E Y.i✓E y., Section 5 , T I N. R 7 E 4esit=if Lot#S'i/ City <br /> Subdivision Name, nearest road lake or landmark Blk# Village e���/� <br /> Je��/ Township�y�ls[.Teti <br /> G A/D�F E1'T 049( ciacc6, ORr <br /> C. TYPE OF OCCUPANCY: Commercial `Industrial 'Other (specify) 'Variance <br /> Single family 7/ Duplex No. of Bedrooms 9 No. of Persons__ <br /> D. SEPTIC TANK CAPACITY/.P0 0 Total .allons No. of tanks / <br /> HOLDING TANK CAPACITY Total •allons No. of tanks <br /> Prefab concrete ✓ Poured-in-Place Steel Fiberglass Other (specify) <br /> New Installation g• Replacement <br /> Lift Pump Tank or Siphon Chamber Total gal ons Prefab concrete Poured-in-Place. Other(Specify) <br /> E. EFFLUENT DISPOSAL SYSTEM: Percolation Ra •miaQ Total Absorb Area 96O sq.ft. <br /> New ✓ Replacement Alternat. (Specify) <br /> Seepage Trench: No.of Lineal Ft. Width _.,, Tile depth(to No.of Trenches- <br /> Seepage Bed:-- <br /> —Length V O Width 2 Depth 2 30 Tile depth(top a1 No.of Line• a <br /> Seepage Pit: Inside diameter Liqui. Depth No.of Seepage Pits <br /> Percent slope of land 3—�/7 Distance from critical slope f.2..ea <br /> WATER SUPPLY:Private El Joint Ild"Community❑ Mu cipal❑ <br /> Owners name as listed on EH 115 if other than present owne : <br /> I, the undersigned, do hereby certify that the inf.rmation I have reported is in accord with Section H62.20, <br /> Wisconsin Administrative Code, and that I have siz d the effluent disposal system from the EH-115 prepared <br /> by the Certified Soil Tester, <br /> NAME Jpf670r4#' , , ")9/4-z"../,,tp4 C.S.T. # 51 Q and other information <br /> obtained from s�� ,a IR , , (owner/builder). G <br /> Plumber's Signature It]�7/+/.7:�APA�/ aaonsoocWlk 296 f Phone #(7/—p -r <br /> Plumber's Address '7' '� -+ �` `� /6' 9' <br /> PLAN VIEW: Provide sketch below of system(inclu. di action of slope and all distances in accord with H62.20.Well loca- <br /> tion shall be included on the sketch. icate dimension location of all wells on the property or neighbors <br /> property.If well has not been drill . . :ase indic�e. <br /> I � 1 � I I i I (� <br /> L-- .i___ .1 I _...1_._ � _ �__ 1 i 0► <br /> r._, .; -i -i r — , —E-- a-- <br /> V � I � I —T <br /> i I _i___,I 1 ef I <br /> S _ ; i� ' I — <br /> 1 j 1 i"' ---t — ''--4— -i - <br /> '- t r j j � t — t I I I f It <br /> t- t , CIA.r +c � � <br /> i -1 '!_ i I_ t1 i T _t-i--_t t--1- 1 } - <br /> f � — It . . ifc I • I I L ! <br /> _- - -- - - _ <br /> 1 e <br /> I I <br /> i I : � � ! I i i I I `I I , -r-1-, i I <br /> l i I 1 , I <br /> i__________ <br /> d? i _i __ '_ i ( ! { <br /> i i 1. 1 ! i � I i i +, I i i i I ( i I <br /> Do Not Write in Space Below - FOR CO TY D 'TATE DEPARTMENT USE NLY <br /> Date of Application fD' 3 • 0 Fe P d: Stat: 'S�• Coun Da�t <br /> Permit Issued/Rejected (date) .'- i ' Iswin• Agent Name r/��i•� ) vv�lQ.t'�l� p wz — <br /> Inspection -Yes Na U Sta e Valid# Date Recd <br /> 1. county (white copy) 3. owner (green .py) DIVISION OF HEALTH,P.O.BOX 309,MADISON,WI 53701 <br /> 2. state (pink copy) 4. plumber (canary •.py) Revised Date 7/1 8 <br />